confusion onset after lowering BP & Glucose too fast?

  1. 0
    I work in a PCU and admitted a patient from the ED this morning around 10:30 with a blood sugar of 495 (ED did not treat the hyperglycemia) and a blood pressure in the 170's over 90's. Patient presented with shortness of breath and an initial B/P in the 200's over 100's. No direct antihypertensives were given in the ED, just IV Lasix and Nitro paste.

    The admitting doctor initiated her orders after I received the patient and over the next 5 hours we lowered her blood pressure to 112/65 and her blood sugar was lowered from 495 to 175 during that same time frame with 20 units of novolog and 23 units of levemir (given during the noon meal).

    The patient was resting comfortably with no complaints of anything at all until just before the evening meal when she complained of severe headache (9/10) and nausea, and skin was clammy. 20 minutes later after some zofran and 0.5 of dilaudid the patient was noted to be confused and acting strangely and saying she "just didn't feel right". The patient was on a cardiac monitor and her rate and rhythm did not change during any of this, she stayed in normal sinus the whole day, rate in the 70s, 80s.

    The patient had a history of CVA, MI, CABG, HTN, and DMII. She had been noncompliant with home meds for some months due to financial difficulty.

    I called the primary doc and was given orders for CT Head/Brain w/o contrast. The CT report came back negative for hemorrage and showed the old infarct from her previous CVA. As I was leaving my shift for the evening I noticed the doc had also ordered a stat MRI brain.

    My question is, could her symptoms around 17:00 be attributed to lowering her glucose level too fast? Since she had not been on her meds for months her body had become accustomed to being at such a high glucose level and it makes sense that she would feel strange having it brought down into the 170s. Also, is 5 hours too short a time frame to bring down someone's blood pressure from the 200s to the 110s?

    Could it be the combination of the rapid glucose lowering and B/P lowering that caused her to feel so ill and confused?
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  3. 5 Comments so far...

  4. 0
    I wouldn't be concerned so much with how quickly the BP and BG were lowered as I would with how much they were lowered, especially the BP. I don't think a period of 5 hours is too quickly for either of these. Unfortunately, there are pieces to this puzzle missing. A. Was her previous CVA embolic or hemorrhagic? (I'm assuming embolic because the CT showed an old infarct. Patients and families can rarely tell you this information, you can usually only find if you have access to old medical records.) B. Any known carotid artery disease (especially in presence of previous embolic CVA)? C. What were her BP and BG at the time of her complaints? D. What is the patient's age?

    I think you are right that the BG level can make a patient who is accustomed to a higher level feel "strange". What may concern me more is that she may not be adequately perfusing her brain if she has carotid stenosis. Those patients require a much higher pressure for adequate cerebral perfusion. When I worked neuro ICU we would frequently use vasopressors in order to keep patients pressures above 140-150.

    Hypoperfusion and/or hypoglycemia both need to be considered especially with the "clammy" skin. Perfusion is not dependent on heart rate, it is dependent on blood pressure. You can have a heart rate of 35 but a blood pressure of 150/75. Conversely, you can have a heart rate of 70 but a blood pressure of 60/30. Clearly, the patient with the heart rate of 35 is perfusing better than the patient with the heart rate of 70 in this case.

    Also, if the patient is elderly the confusion after hydromorphone would not be that uncommon. What is most concerning though is the sudden headache, especially in the setting you described. While the CT can rule out acute bleeding in the brain, it cannot rule out ischemia. Also, I do not think it can rule out brain stem infarcts/bleeding. For that, you do need MRI if I remember correctly (It has been several years since I worked neuro). Also, bear in mind that ischemic injury does not show immediately on a CT scan. This can take up to 48 hours to show. The first CT after neuro changes is generally only used to rule out bleeding.

    Anyway, enough useless trivia from me. In short (too late for that, ha) I don't think the time span you described is unreasonable. Also, I do think you were definitely thinking along the right lines in trying to pinpoint the cause of her symptoms and I think you did everything right. Your assessment and re-assessment of the patient is very impressive!
  5. 0
    Yes, people that are non-compliant with their meds or have been off them for some time do not tolerate "normal" BP and BS. The rate in which the BP and BS were lowered is a concern. I currently work trauma ICU and we get all the heads that requires the ICU. We tend to lower their pressure slowly to prevent them from stroking out by lowering their pressure to rapidly. Previous poster is correct, the brain may not be perfussing in the 110's when they have been used to the 200's.. HTN crisis is managed about the same, I forget the exact numbers but we don't like to drop more than 30 points over 6-8 hours. This allows the brain time to adjust..

    As far as the BS, you are right, the pt is not tolerating the lower numbers because the body as been high for X amount of time, we also lower them slowly as well. Many of our pts that come in with DKA or that have really high BS levels are placed on a insulin gtt and monitored closely. They can be on the gtt for 24 hours or more..
  6. 2
    Quote from clickhand
    I work in a PCU and admitted a patient from the ED this morning around 10:30 with a blood sugar of 495 (ED did not treat the hyperglycemia) and a blood pressure in the 170's over 90's. Patient presented with shortness of breath and an initial B/P in the 200's over 100's. No direct antihypertensives were given in the ED, just IV Lasix and Nitro paste.

    The admitting doctor initiated her orders after I received the patient and over the next 5 hours we lowered her blood pressure to 112/65 and her blood sugar was lowered from 495 to 175 during that same time frame with 20 units of novolog and 23 units of levemir (given during the noon meal).

    The patient was resting comfortably with no complaints of anything at all until just before the evening meal when she complained of severe headache (9/10) and nausea, and skin was clammy. 20 minutes later after some zofran and 0.5 of dilaudid the patient was noted to be confused and acting strangely and saying she "just didn't feel right". The patient was on a cardiac monitor and her rate and rhythm did not change during any of this, she stayed in normal sinus the whole day, rate in the 70s, 80s.

    The patient had a history of CVA, MI, CABG, HTN, and DMII. She had been noncompliant with home meds for some months due to financial difficulty.

    I called the primary doc and was given orders for CT Head/Brain w/o contrast. The CT report came back negative for hemorrage and showed the old infarct from her previous CVA. As I was leaving my shift for the evening I noticed the doc had also ordered a stat MRI brain.
    First I don't consider patients non-compliant with meds when they can't afford them. If you have to choose between eating and having water and heat/being homeless or having your meds...the choice is simple...sad that in the US our elderly/needy have to resort to this. Non compliance is by choice.

    Second.....the ED did give something to lower the B/P...they gave Lasix and Nitropaste. So you diuresed this patient and vasodilated her. You gave insulin to lower her blood sugar.

    She then complained of a 9/10 H/A (a side effect of nitro and dehydration due to diuresis from the lasix and possibly lowered glucose) nausea and and gave her Zofran and dilaudid.

    Did you check her B/P at that time? what was her glucose at that time? How much had she diuresed by then? What were her vital signs after the Zofran/dilaudid? What are the side effects of Zofran and dilaudid? What was her glucose at that time after the dilaudid/zofran? what were her vitals?

    I am not sure she needed a CT scan....the headache could be from the Nitro. The nausea from the headache. The diaphoresis from the sudden decrease of her glucose, even if the Fingerstick was within normal range.....since she is probably accustomed to a higher baseline.....combined with the Zofran and Dilaudid IV
    My question is, could her symptoms around 17:00 be attributed to lowering her glucose level too fast? Since she had not been on her meds for months her body had become accustomed to being at such a high glucose level and it makes sense that she would feel strange having it brought down into the 170s. Also, is 5 hours too short a time frame to bring down someone's blood pressure from the 200s to the 110s?

    Could it be the combination of the rapid glucose lowering and B/P lowering that caused her to feel so ill and confused?
    No it is not too fast ......many patients have rapid correction in a mater of minutes in an ICU setting with IV meds. Some patients are more sensitive to meds than others.

    IMHO this was caused by a combination of meds, Lasix, nitro, insulin.... coupled with Zofran and Dilaudid IV that made her feel SOOOOOO bad.

    The nitro paste and diuresis from lasix gave her a severe headache as well as correcting her glucose (how do you feel when you haven't eaten in a long time on a hot day and you haven't eaten nor drank very much....you feel like crap and have a headache...right?) Then you give zofran and dilaudid IV no less......which can make ANYONE feel weird, diaphoretic and confused......

    I'm not sure the CT MRI we all that necessary....but then I didn't assess the patient.
    Last edit by Esme12 on Jun 16, '13
    NurseJoy33 and turnforthenurseRN like this.
  7. 1
    In terms of lowering blood sugar, you should do it by 70-100/hr. Doing so too quickly (>100/hr) can potentially lead to cerebral edema. Otherwise I think Esme pretty much covered it.
    Esme12 likes this.
  8. 0
    Sounds like a med cascade to me, but it's hard to tell without seeing the pt and allowing all the details. I think I would have imaged her anyways especially if she had a hx of hemorrhagic stroke or other bleed risk just to rule out a SAH. Did she have any focal neuro signs?


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